Post on 08-Feb-2021
Supporting families earlySAFE START strategic policy
FAMILIES NSW SUPPORTING FAMILIES EARLY PACKAGE
NSW DEPARTMENT OF HEALTH
73 Miller Street
NORTH SYDNEY NSW 2060
Tel. (02) 9391 9000
Fax. (02) 9391 9101
TTY. (02) 9391 9900
www.health.nsw.gov.au
This work is copyright. It may be reproduced in whole or in part for study
training purposes subject to the inclusion of an acknowledgement of the source.
It may not be reproduced for commercial usage or sale. Reproduction for
purposes other than those indicated above requires written permission from
the NSW Department of Health.
Suggested reference: NSW Department of Health, 2009, NSW Health/Families
NSW Supporting Families Early Package – SAFE START Strategic Policy,
NSW Department of Health
© NSW Department of Health 2009
SHPN (PHCP) 080164
ISBN 9781 74187 285 9
Further copies of this document can be downloaded from the
NSW Health website www.health.nsw.gov.au
June 2009
NSW HealtH SaFe StaRt strategic policy PaGe �
The NSW Health / Families NSW Supporting Families
Early package brings together initiatives from NSW
Health’s Primary Health and Community Partnerships
Branch and Mental Health and Drug & Alcohol Office.
It promotes an integrated approach to the care of
women, their infants and families in the perinatal period.
Three companion documents form the Families NSW
Supporting Families Early package.
Supporting families early maternal and child health primary health care policy
The first part of the package is the Supporting Families
Early Maternal and Child Health Primary Health Care
Policy. It identifies a model for the provision of universal
assessment, coordinated care, and home visiting, by
NSW Health’s maternity and community health services,
for all parents expecting or caring for a new baby.
This model is described within the context of current
maternity and child and family health service systems.
SaFe StaRt strategic policy
The second part of the package, the SAFE START
Strategic Policy, provides direction for the provision of
coordinated and planned mental health responses to
primary health workers involved in the identification of
families at risk of developing, or with, mental health
problems, during the critical perinatal period. It outlines
the core structure and components required by NSW
mental health services to develop and implement the
SAFE START model.
SaFe StaRt guidelines: improving mental health outcomes for parents and infants
The third part of the package, the SAFE START
Guidelines: Improving Mental Health Outcomes
for Parents and Infants, outlines the rationale for
psychosocial assessment, risk prevention and early
intervention. It proposes a spectrum of coordinated
clinical responses to the various configurations of risk
factors and mental health issues identified through
psychosocial assessment and depression screening in
the perinatal period. It also outlines the importance of
the broader specialist role of mental health services in
addressing the needs of parents at risk of developing, or
with, mental health problems.
NSW Health / Families NSW Supporting Families Early package
PaGe �� NSW HealtH SaFe StaRt strategic policy
Pregnancy and becoming a parent is usually an exciting
time, full of anticipation, joy and hope. It can also be a
time of uncertainty or anxiety for parents and families.
To support families fully during what can be a stressful
period, it is important to address the range of physical,
psychological and social issues affecting the infant and
family. This range of issues and parents’ understanding
of the tasks and roles of parenthood are recognised
as significant influences on the capacity of parents
to provide a positive environment that encourages
optimum development of the infant.
Providing support for infants, children and parents,
beginning in pregnancy, including their physical and
mental health, is a key priority of the NSW Government.
This is clearly articulated in the NSW Action Plan
for Early Childhood and Child Care which is part of
the Council of Australian Government’s National
Reform Agenda, the NSW State Plan, and the NSW
State Health Plan.
The NSW whole-of-government Families NSW initiative
is an overarching strategy to enhance the health and
wellbeing of children up to 8 years and their families.
One way it does this is by improving the way agencies
work together, so that parents get the services, support
and information they need.
NSW Health is a key partner with other human service
agencies in developing prevention and early intervention
services that assist parents and communities to sustain
children’s health and wellbeing in the long term. Health
services are the universal point of contact for these
families entering the Families NSW service system.
NSW Health’s vision is for a comprehensive and integrated
health response for families. This response will encompass
all stages of pregnancy and early childhood development
and link hospital, community and specialist health
services. The aim is to assist families in the transition to
parenthood, build on their strengths, and ameliorate any
identified risks that can contribute to the development of
problems in infants and later on in life.
The NSW Health / Families NSW Supporting Families
Early package integrates three NSW Health initiatives that
are underpinned by a common understanding of the
challenges that parenthood can involve, the importance
of the early years of a child’s development, and the
benefits of appropriate early intervention programs. The
initiatives contained within Supporting Families Early are
an important contribution to the provision of services that
enhance the health of parents and their infants, help to
protect against child abuse and neglect, and enhance the
wellbeing of the whole community.
Professor Debora Picone AM
Director-General
NSW Health
Message from the Director-General
NSW HealtH SaFe StaRt strategic policy PaGe �
Families NSW Supporting Families early package .............................................................. i
Message from the Director‑General ................................................................................... ii
Section �. Rationale – Why a focus on SaFe StaRt?........................................................ 2
1.2 Overview of the SAFE START model ..............................................................................................4
1.3 The policy and planning context ...................................................................................................5
Section 2. Core principles of SaFe StaRt .......................................................................... 7
Section 3. SaFe StaRt strategic action plan ..................................................................... 8
Strategy 1: Planning and partnerships .....................................................................................................8
Strategy 2: Implementation of the SAFE START model ............................................................................9
Strategy 3: A supported and skilled workforce ......................................................................................10
Strategy 4: Mental health care for pregnant women and families with an infant up to two years ....................................................................................................11
Strategy 5: Sustainable, effective SAFE START ......................................................................................12
aPPeND�CeS
1A Edinburgh post natal depression scale (EPDS) .................................................... .............................13
1B Edinburgh depression scale (antenatal) (EDS)... ........................................................................... .14
1C Edinburgh depression scale (EPDS/EDS) scoring guide .................................................................15
2 Psychosocial risk variables I-VII ....................................................................................................16
3 Strengths and issues - models of SAFE START implementation ....................................................17
References .......................................................................................................................... �8
Contents
PaGe 2 NSW HealtH SaFe StaRt strategic policy
Infancy is a crucial developmental phase with
implications for later mental health. Providing infants
with opportunities for healthy development is a key
strategy in building resilience and reducing mental
health problems across the life span.
From birth, infants are very sensitive to the emotional
states of their caregivers. Parenting style, the quality
of attachment relationships and family context during
the first few years of life have long-lasting effects on
neurobiological and socio-emotional development.
Infant development occurs in the context of care-giving
relationships and infants learn to regulate their emotions
and understand relationship experiences through the
profound early relationship with their parent or care
giver. That is, their attachment figure.
Healthy attachment relationships promote optimal infant
development. Parents who are experiencing adverse
relationships (current or unresolved memories of past
difficult relationships) and emotional distress or anxiety
states, will understandably find it challenging to remain
attuned and sensitively responsive to their infant’s needs.
The impact of poor parental mental health on childhood
emotional, cognitive and social development and its
trajectory into adulthood has been identified as a key
focus area for NSW Health.
The SAFE START model aims to enhance the mental and
physical health of parents and their infants by providing
a consistent model for psychosocial assessment and
depression screening for women expecting or caring
for an infant, and by supporting the development
of local networks of services, which will work
collaboratively to support families. The SAFE START
model also aims at early identification of parental
mental health problems, reduction of relapse rate
and lowering of the impact of parental mental illness
on the infant, whilst preserving the family unit.
�ncreased levels of depression and anxiety symptoms during
pregnancy contribute independently of
other biomedical risk factors to adverse obstetric, fetal and
neonatal outcome (alder et al., 2007).
Parenting behaviour critically shapes human infants’ current
and future behavior. the parent‑infant relationship provides
infants with their first social experiences, forming templates
of what they can expect from others and how to best meet
others’ expectations throughout childhood and adult life
(Swain et al., 2007).
Rationale – Why a focus on SAFE START?
SECTION 1
Perinatal mental health statistics
Common mental health problems during the antenatal and
postnatal period include depression and anxiety disorders,
such as panic disorder, obsessive compulsive disorder (OCD)
and post traumatic stress disorder (PtSD). an estimated �0%
to �5% of women suffer from depression after the birth of
an infant. For the vast majority of these women, professional
help will be provided solely by primary health care services in
community settings (National Collaborating Centre for Mental
Health, 2007).
around 3% to 5% of women giving birth have moderate or
severe depression, with about �.7% of these women being
referred to specialist mental health services (Cox, Murray &
Chapman, �993).
First presentations of severe mental illness, primarily
schizophrenia and bipolar disorder, in the perinatal period are
rare, with a rate in the region of two per thousand resulting in
hospital admissions (Kendell, Chalmers & Platz, �987).
More common, particularly with bipolar disorder, is the
exacerbation of an existing disorder, with some studies
reporting relapse rates for bipolar disorder approaching 50%
in the antenatal period and 70% in the postnatal period
(Viguera, Nonacs, Cohen, et al., 2000).
these women, along with others suffering from severe
depression and other severe disorders such as severe anxiety
disorders or personality disorders will benefit from integrated
specialist mental health care (National Collaborating Centre for
Mental Health, 2007).
�n australia it has been estimated that between 25‑50% of
children and young people with parents with mental illness
experience psychological disorder (Barnett, Schaafsma,
Guzman & Parker, �99�).
■
■
■
■
■
■
NSW HealtH SaFe StaRt strategic policy PaGe 3
The terms “perinatal and infancy period” and “pregnancy
and postnatal period” in the SAFE START documents
describe the period from conception to two years after
delivery. They are used to emphasise the significance
of problems that can arise in the pregnancy and early
parenting periods. These terms also recognise the
importance of infant brain development in the context of
the primary care-giving relationship during the first two
years, and the critical manner in which this early infant
development influences outcomes across the lifespan.
This approach regards pregnancy as a crucial period for
early intervention, and recognises the need for extended
or sustained support for some mothers, infants and
their families in the first two years of the infant’s
development.
The term “caregiver(s)” is frequently used in the SAFE
START documents instead of “mothers” or “parents”
in recognition of the fact that the infant needs the
consistent nurturing of a caring adult who may not
necessarily be the biological mother. The important
role of fathers/partners, relatives or foster carers who
share the immediate care of the child is recognised as
essential.
SAFE START provides a framework using a population
health model for mothers, infants and their families.
SAFE START involves universal psychosocial risk
assessment and depression screening for all women as
part of a comprehensive health assessment during both
pregnancy and the postnatal periods. This is linked to
a network of supports and health-related services for
those mothers, infants and families at risk of adverse
physical and mental health outcomes (Appendix 1).
A range of bio-psychosocial factors may impact on
parenting capacity and the provision of a safe,
physical and emotional environment for the infant.
Identification of parental risk factors is the first step in
prevention of risk for infants development. Evidence
from neuroscience, epidemiology, sociology and
developmental psychology has highlighted the vital
nature of brain development during gestation and the
first years of life on learning and behaviour, and the
complex, intricate interplay between brain development
in the infant and appropriate stimulation delivered to
the child through nurturing and positive parenting. This
exchange can be influenced by various psychological
and social factors such as poverty, domestic violence,
anxiety, depression and other mental health problems
and disorders. These factors may affect the nurturing
process and the growth of the infant.
The SAFE START Strategic Policy defines the core
principles underpinning the initiative. It identifies five
strategies to guide Mental Health Service managers,
policy makers and clinicians to effectively and
comprehensively implement the SAFE START model.
Forming strong relationships and attachments involves understanding the needs of the other, providing care and protection, and a preoccupation with the interests and wants of the other. the human transition to parenthood involves a set of highly conserved behaviours and mental states, reflecting both genetic endowment and early life experience – including the intrauterine environment. apart from parenting, there are many other forms of interpersonal relationship – adoption, foster care, step‑parenting, teaching, mentoring, grandparenting as well as friendship and romantic love – each involving similar genetic, neurobiological and experiential systems that have the potential to inform clinical practice, particularly early intervention programs for high‑risk expectant parents (Swain et al., 2007).
to paraphrase Winnicott (�960), ‘good enough’ genes combined with good enough parental care ensure positive outcomes in childhood and beyond. Unfortunately, ‘good enough’ circumstances are often not available. (Cited in Swain et al., 2007).each year, many children become victims of abuse or neglect, with a biological parent identified as the perpetrator in the majority of cases.abuse and neglect perpetrated by a child’s biological parent represents a fundamental breakdown in this important attachment relationship, resulting in serious long‑term consequences for the offspring (Swain et al., 2007).
PaGe � NSW HealtH SaFe StaRt strategic policy
1.2 Overview of the SaFe StaRt model
Families NSW, which is coordinated through the
Communities Division in the NSW Department of
Community Services (DoCS), aims to improve the
effectiveness of prevention and early intervention
services for families with children aged 0–8 years. SAFE
START is one of the core strategies to link prevention
and early intervention services and programs.
Pregnancy and infancy are ideal times for families
to be engaged in a range of professional support
services. Antenatal Clinics and Early Childhood Health
Centres provide high-quality assessment of health and
support needs for mothers and their babies during
this crucial developmental period. The SAFE START
model incorporates psychosocial factors and depression
screening into the assessment process to identify
psychosocial difficulties and/or current depression in all
pregnant and postnatal women. Psychosocial difficulties
and depression during pregnancy and after the birth of a
baby may impact on parenting. The SAFE START model
provides a framework to access appropriate support and
care provided by maternity staff, child & family health
nurses, secondary-level services (e.g. allied health) and
specialist health services including mental health and drug
& alcohol services.
It is anticipated that all Area Health Services (AHSs) in
NSW will implement, or further implement, the SAFE
START model so that psychosocial assessment and
depression screening are provided for all women at the
time of the antenatal booking-in assessment and again
in the community setting, after the birth of the baby.
The universality of the psychosocial assessment and
depression screening is important because risk factors
for poor mental health outcomes span the spectrum
of socio-economic and cultural groups. Because the
people who are most at risk are sometimes reluctant to
engage with services, assertive and sensitive relationship
building approaches during the assessment process are
essential to avoid being stigmatising for families.
The purpose of psychosocial risk assessment and
depression screening for all women that are expecting
or caring for a baby is to embed mental health
promotion, prevention and early intervention practice
throughout the perinatal period, for all families.
Psychosocial assessment and depression screening must
be implemented and maintained in conjunction with a
spectrum of support and intervention options according
to number of risk factors, levels of adversity, strengths
and resources within each individual family.
Equitable and timely access to family-focused assessment
and supportive interventions for families with
complex problems including substance abuse, mental
health problems and/or domestic violence is crucial.
Multidimensional assessment undertaken collectively and
collaboratively by relevant health professionals should
focus on the parents (as individuals and parenting couple),
the child and entire family system. Inter-service and inter-
team collaboration to periodically deploy relevant health
professionals to participate in multidimensional parent-
infant-family assessment processes may optimise infant
and family health outcomes through correctly identifying
parent-infant relationship risks (and strengths, and
targeting interventions accordingly.
The SAFE START psychosocial assessment format will
be standardised throughout NSW Health Services to
promote universality throughout the health workforce.
1.3 the policy and planning context
The SAFE START Strategic Policy is informed by national
policy documents including the National Mental Health
Policy (Australian Health Ministers, 1992), Mental
Health Statement of Rights and Responsibilities
(Australian Health Ministers, 1992), National Mental
Health Plan (Australian Health Ministers, 2003),
National Action Plan on Mental Health (Council of
Australian Governments, 2006) and the National Action
Plan for Promotion, Prevention and Early Intervention
for Mental Health (Commonwealth Department of
Health and Aged Care, 2000).
NSW HealtH SaFe StaRt strategic policy PaGe 5
NSW: A New Direction for Mental Health
Released in July 2006, this Plan outlines significant
investment by the NSW Government over five years
to reform mental health services to ensure the right
care can be provided at the right time. It aims to
balance hospital focussed care with community care, by
building stronger links between the public, private and
community services, between hospitals and GPs and
between the State and Federal Governments. The Plan
aims to achieve change through four areas of effort:
Promotion, prevention and early intervention
across the lifespan
Improving and integrating the care system
Participation in the community and
employment including accommodation
Better workforce capacity.
The NSW Government recognises the importance of
activities to promote better mental health for everyone,
prevent and minimise risk factors and intervene early
to improve treatment outcomes. This commitment to
promotion, prevention and early intervention encourages
working in partnership with stakeholders to increase
community awareness and knowledge of ways to
promote good mental health and reduce stigma.
NSW Mental Health is committed to implementing
programs that build resilience in young people,
reduce the risk factors associated with drug use, and
intervening early with high-risk families.
A strategic approach to mental health policy in NSW
encapsulates a whole-of-government commitment to
improving the mental health and wellbeing of the
NSW community. This has been achieved through
the development of two companion plans:
NSW Interagency Action Plan recognises that
a number of government agencies have a role to play
in responding to the needs of people affected by mental
illness and sets out a coordinated approach for agencies
to work better together.
■
■
■
■
NSW Community Mental Health Strategy
The NSW Community Mental Health Strategy
2007–2012 describes the model for community Mental
Health Services in NSW. It covers services delivered
across the age range, across diverse communities and in
collaboration with service partners. The purpose of the
Strategy is to guide NSW Health, NSW Aboriginal Mental
Health Services, and NGOs in the implementation of this
model. It aims to achieve improved outcomes in mental
health by delivering comprehensive recovery oriented
community mental health services across NSW that will:
Promote mental health and wellbeing
Embed a recovery approach to service delivery
Prevent and/or intervene early in the onset or
recurrence of mental illness
Improve evidence based practice in community
supports and services
Enhance community responses to mental health
emergencies and acute care needs.
■
■
■
■
■
PaGe 6 NSW HealtH SaFe StaRt strategic policy
A Secure Base For The Future: Nsw Mental Health
Service Plan For Children, Adolescents And The
People Who Care For Them
The development of Building A Secure Base For The
Future: NSW Mental Health Service Plan For Children,
Adolescents And The People Who Care For Them has
involved an extensive consultation process. The Plan
aims to improve the mental health of children and
adolescents, to help them, their families and others
caring for them to optimise their development and build
a secure base for their futures. It outlines the principles
for service development over a ten year period.
The Plan adopts the term Child and Adolescent Mental
Health Services (CAMHS). This terminology is consistent
with National Mental Health reporting frameworks in
reference to services for the population aged 0–17 years
inclusive. Under this convention, an infant is included
in the term “child”. Development has also reflected
the context of increasing attention to collaborative
interagency and cross-service partnerships to foster the
mental health of children and adolescents and to protect
children and young people. Perinatal and infant mental
health are areas specifically identified in the plan as
especially suited to integration across CAMHS and adult
mental health services, linked to health more broadly.
SAFE START embraces a population health model
(Mrazek & Haggerty, 1994), which outlines the range
of services and interventions required to ensure good
mental health care for individuals, their families and
communities. The spectrum of care encompasses health
promotion and prevention, early intervention, treatment,
recovery and continuing care. The strategies developed
in this SAFE START Policy address aspects of the
population health model, from prevention to specialist
intervention, with an emphasis on the specific needs of
families during pregnancy and the postnatal period.
NSW HealtH SaFe StaRt strategic policy PaGe 7
Core principles of SAFE START
SECTION 2
SAFE START promotes continuity of family care
throughout pregnancy, postnatal and early
childhood periods.
SAFE START recognises the significance of risk and
protective factors in health. The complex interaction
between risk and resilience is acknowledged as well as the
strengths and diversity of local communities
in the determinants of health.
SAFE START acknowledges the role of parents and
family systems in providing sound foundations for the
healthy development of children. The vital role of support
systems, especially fathers or partners, is identified and
opportunities to include them
and participate in care.
■
■
■
SAFE START interventions are undertaken as early as
possible and are flexible enough to respond to variations
in individual and family circumstances.
A comprehensive network of local resources
and services is required. These include hospital
and community health services, General
Practitioners, primary health and specialist health services,
including mental health and drug & alcohol services, and
includes government and
non-government community agencies.
The formation of partnerships for service delivery is
essential. This involves active partnerships based on
communication, collaboration and cooperation between
the mother, her family and various professionals across the
spectrum of care.
■
■
■
PaGe 8 NSW HealtH SaFe StaRt strategic policy
Strategy 1: Planning and partnershipsExpected outcomes: Develop a multidisciplinary and multi-agency system of family-focused health care
for pregnant women and families with infants up to two years age.
Actions Performance indicators Agency
1.1 Identify existing Families NSW, Health Home Visiting and Perinatal networks and structures within the
AHS; and identify lead SAFE START position within
the AHS.
Relevant existing structures, and positions
identified.
■ AHS1
1.2 Establish Area SAFE START implementation
committee that includes representatives from
Senior Management and frontline staff from
Divisions, Sectors and Agencies providing
health care for families through pregnancy
and early parenting.
SAFE START implementation committee
linked with Families NSW; reflected in the Families NSW regional implementation plan.
Membership of committee: Senior Health
Managers from Divisions, Sectors or Clusters
(particularly from Maternity, Child and Family
Health, Mental Health and Drug & Alcohol services)
are matched in terms of level of seniority.
■
■
AHS
1.3 Develop an Area SAFE START plan that localises
implementation of the SAFE START Strategic Policy.Area SAFE START plan complete and endorsed.■ AHS
1.4 Implementation and evaluation
of Area SAFE START plan in collaboration with
Families NSW Coordinators, Child and Family Health Managers and Maternity Service Managers,
Mental Health and Drug & Alcohol Managers.
Formal communication pathways established for
implementation of the Area SAFE START plan
through relevant governance and reporting.
■ AHS
1.5 Identify strategies to engage the primary health
and private sector (GPs, private obstetricians,
private psychiatrists and therapists) in collaborative
care for families with complex needs who are
pregnant or have an infant(s) up to two years age.
Formal links with General Practitioner (GP)
Shared-Care programs including referral pathways.
Strategies that inform the private sector and that
support the development of working partnerships.
■
■
DOH2
AHS
1.6 Link SAFE START and Children of Parents with
Mental Illness (COPMI) strategic plans to support
consistent service planning and delivery of care
to all children of parents with a mental illness and
their families, from the time of conception.
Formal links between SAFE START and Children
of Parents with a Mental Illness – (COPMI)
NSW (State) and Area Strategic Plans to deliver
seamless modes of intervention throughout
developmental stages.
■ MHDAO3
MH-Kids4
AHS
1 Area Health Service (AHS)
2 NSW Department of Health (DOH)
3 Mental Health and Drug & Alcohol Office (MHDAO)
4 MH-Kids (an Area hosted unit of MHDAO)
SAFE START strategic action plan
SECTION 3
NSW HealtH SaFe StaRt strategic policy PaGe 9
Strategy 2: Implementation of the SAFE START modelExpected outcomes: Early identification of psychosocial risk and depressive symptoms and timely access
to appropriate interventions for pregnant women and families with infants up to two years of age.
Actions Performance indicators Agency
2.1 Ensure that universal psychosocial
assessment and depression screening
are implemented in maternity and
early childhood health services
throughout each AHS; including
formal adoption by Area of validated
tools and domains of psychosocial risk
assessment.
Psychosocial assessment tool includes the 7 identified key
variables (domains of risk to be assessed – Appendix 2.
Edinburgh Depression Scale (EDS/EPDS) routinely used as
recommended by SAFE START Guidelines document.
Proportion of women attending public Maternity and Child
and Family Health services who are offered psychosocial
assessment and depression screening, and number of clients who
receive intervention when indicated. Annual reports to DOH.
■
■
■
AHS
2.2 Develop and implement
multidisciplinary, inter-sectoral
(multi-agency) intake procedures
in Maternity and Child and Family
Health settings for the allocation
of vulnerable families to appropriate
care pathway; including collaborative
care when required.
Area/Sector Cluster intake policy developed and endorsed for
families with complex needs and who are expecting or caring for
an infant.
Regular clinical planning meetings in all Maternity and Child and
Family Health settings with representation from: Mental Health;
Drug and Alcohol; Aboriginal Health; Multicultural Health, and;
other relevant Services.
Triage, Intake and Assessment protocols in Adult and Child
and Adolescent Mental Health, and Drug & alcohol services
focusing on pregnant women and parents with children up
to two years of age.
■
■
■
AHS
AHS &
MHDAO
2.3 Identification of perinatal and infant
clients in mental health services.
Include identification of ‘perinatal’ client in Child and Adolescent
and Adult Mental Health client registration and data collection
(adolescent or adult women who are pregnant or have an infant
up to two years age.)
Include identification of ‘parent of an infant’ in Child and
Adolescent and Adult Mental Health client registation and data
collection (any person who lives with or provides regular care for
an infant up to two years age – or lives with a pregnant woman).
Development of Mental Health client registration, standardised
assessment format, and data collection for children 0–2 years.
■
■
■
MHDAO
MH-Kids
InforMH
2.4 Assess specialist services’ capacity
to intervene effectively when women
who are pregnant or caring for
an infant up to two years age are
identified with risk factors requiring
early intervention.
Develop solutions to remedy service
integration gaps.
Local scoping document of existing resources, services roles and
service responsibilities in regard to SAFE START to be undertaken
by Area Mental Health and Drug & Alcohol services.
Evidence of strategies undertaken at Area and State level to
reduce gaps in integrated service delivery for women who
are pregnant and families with an infant up to two years age
(eg collaborative, cross-boundary assessment; prioritisation
strategies; formulation of links to specialist perinatal psychiatry
consultation through supra-regional teleconferencing; forging of
partnerships within and outside health and with specialist early
parenting services such as Karitane and Tresillian).
■
■
AHS &
MHDAO
MH-Kids
PaGe �0 NSW HealtH SaFe StaRt strategic policy
Strategy 3: A supported and skilled workforceExpected outcomes: Enhanced knowledge and skills of health and related workers to deliver psychosocial
assessment and depression screening; and in the provision of early mental health interventions for mothers,
infants and their families.
Actions Performance indicators Agency
3.1 Sustainable SAFE START training and education
strategy implemented in each AHS.
Online SAFE START Education and Training available to
each AHS in 2009.
Area SAFE START training and education plan endorsed
and Coordinator identified.
Proportion (benchmark) of midwives and child and
family health nurses completing SAFE START Training.
SAFE START training embedded in orientation process
for all relevant service sectors.
■
■
■
■
MHDAO
AHS
AHS
AHS
3.2 Identify Mental Health and Drug & Alcohol
workers to attend SAFE START specialist
Training; and other relevant, specialised
perinatal and infant mental health, attachment
and early parenting training as available.
SAFE START Specialist Education and Training available
to each AHS in 2009-2010.
Proportion of Mental Health and Drug and Alcohol
educators and clinicians attending SAFE START
Specialist Education and Training session.
■
■
MHDAO
MH-Kids
AHS
3.3 Foster collaborative partnerships between
Mental Health, Maternity and Child and
Family Services, GPs, DoCS and other relevant
service providers to improve development
of and access to individual, group or peer
supervision, or reflective case discussion
groups relevant to families with complex needs
– conception to two years age.
Local formal partnerships (eg Memorandum of
Understanding, Service agreement, or policy/protocol)
outlining cross-boundary staff attendance at reflective
case discussion or supervision networks.
Senior Clinical and Management leaders identified
to oversee cross-boundary supervision or reflective
case discussion groups.
■
■
AHS
3.4 Foster collaborative partnership with the
GP Alliance to support access to SAFE START
training for GPs.
Liaise with the Divisions of General Practice.
GP participation in local SAFE START education
and training.
■
■
AHS
3.5 Link SAFE START, COPMI and Parenting for
Mental Health training initiatives to enhance
assessment and early intervention skills and
advanced knowledge in the workforce caring
for mentally ill parents.
SAFE START, COPMI and Parenting for Mental Health
training initiatives integrated at State and Area level.
■ MHDAO
MH-Kids
AHS
3.6 Work with universities, other tertiary education
facilities and professional associations to
incorporate training specific to:
perinatal and infant mental health
psychosocial assessment and depression
screening during pregnancy and the
postnatal period
social and emotional development.
■
■
■
Links with universities and professional associations
established.
Joint appointment (academic-clinical positions)
in Midwifery, Child and Family and Psychiatry based
in AHS/University to be kept abreast
with SAFE START and related education and training
needs of undergraduate medical, nursing and allied
health students.
■
■
MHDAO
MH-Kids
NSW HealtH SaFe StaRt strategic policy PaGe ��
Strategy 4: Mental health care for pregnant women and families with an infant up to two years ageExpected outcomes: Improved access to timely and appropriate integrated care systems for vulnerable
families with infants up to two years age.
Actions Performance indicators Agency
4.1 Improve mental health service integration
with other health care providers to improve
appropriate mental health assessment for
pregnant women and parents who care for
an infant up to two years age.
4.1.1 Review current mental health service intake
policy and assess service capacity to: include
specific responses to pregnant women and
parents who care for an infant up to two years
age; direct joint assessments with Maternity
or Child and Family Health referrers; include
protocol for comprehensive parent-infant
mental health assessment.
Area Mental Health Director involvement in
development and implementation of SAFE START locally
– particularly in relation to local Maternity and Child
and Family Health Service policy related to administering
depression screening and care pathways for response to
risk identified.
Area mental health service policy developed for family-
focused perinatal intake and assessment process.
■
■
AHS
4.2 Identify roles and functions of adult
and child and adolescent Mental Health
Services in the implementation of SAFE START.
Defined lines of responsibility for:
– assessment of parenting capacity, and care of the
mentally ill parent with an infant up to two years age
– monitoring and management of identified problems
within the parent-infant relationship that warrant a
secondary or tertiary level mental health assessment
and collaborative care (eg with DoCS)
– care-coordination, liaison and collaborative care for
parent-infant mental health clients.
■ AHS
4.3 Develop Area Mental Health Action Plans for
perinatal and infant mental health service in
line with Building a Secure Base for the Future: NSW Mental Health Services Plan for Children, Adolescents and the People who Care for them.
Area Mental Health document in line with ‘Building a
Secure Base for the Future’ developed and endorsed
that: defines target population as per Mental Health
Clinical Care and Prevention Model (MH-CCP) and local
service delivery framework with a focus on cross-setting
emergency response, mother-baby mental health
hospital care and community care.
■ AHS/MH
CAMHS
MH-Kids
4.4 I dentify strategies and protocols that
promote and support active partnerships
and collaborative practice between adult and
child and adolescent Mental Health Services.
Regular integrated care planning meetings to support
parallel interventions by adult, child and adolescent
mental health clinicians and child and family clinicians
working with mentally ill parents.
■ AHS/MH
CAMHS
MH-Kids
4.5 Support the development and implementation
of service agreements and policies that foster
active collaboration between Mental Health
services and DoCS during pregnancy and for
families with infants up to two years age to
promote early intervention and prevention
activities prior to parental relapse or infant
mental health problems occurring.
Local Service Agreement or Memorandum of
Understanding (MOU) clarifying role of MH Services
and DoCS in working with parents and infants who
are experiencing mental health problems.
Practice guidelines in place to ensure effective
prenatal reporting and collaborative DoCS – MH Early
Intervention.
■
■
AHS
MH-Kids
MHDAO
4.6 Advocacy for fathers who have a mental illness
and are parenting an infant; adequate support
to ameliorate the impact of the illness on the
family during the perinatal period.
Joint planning and care agreement developed between
Mental Health Services and Primary Health Care Services
including GPs and NGOs.
Assertive relapse prevention approach to support fathers
with mental illness during the perinatal period.
■
■
AHS
PaGe �2 NSW HealtH SaFe StaRt strategic policy
Strategy 5: Sustainable, effective SAFE STARTExpected outcomes: Ongoing performance monitoring demonstrates that pregnant women and families with infants
up to two years age identified as vulnerable are engaged with appropriate specialist assessment and integrated care.
Actions Performance indicators Agency
5.1 Regularly evaluate the effectiveness
of implementation of SAFE START.
SAFE START monitoring and feedback systems developed and in
place.
■ AHS
MHDAO
MH-Kids
NSW HealtH SaFe StaRt strategic policy PaGe �3
Edinburgh post natal depression scale (Cox J, Holden J, Sagovsky R. 1987)
APPENDIx 1A
Date _____________________________ Mother’s name ___________________________________________ Age __________
Baby’s name ________________________________________ Date of birth ___________________________ Sex __________
as you have recently had a baby we would like to
know how you are feeling. Please UNDeRl�Ne the
answer which comes closest to how you have felt
�N tHe PaSt 7 DaYS, not just how you feel today.
Here is an example, already completed.
� have felt happy:
Yes, all the time
Yes, most of the time
No, not very often
No, not at all
this would mean: “� have felt happy most of the
time” during the past week. Complete the other
questions in the same way.
�. � have been able to laugh and see the
funny side of things:
As much as I always could
Not quite so much now
Definitely not so much now
Not at all
2. � have looked forward with enjoyment to things:
As much as I ever did
Rather less than I used to
Definitely less than I used to
Hardly at all
3. � have blamed myself unnecessarily when
things went wrong:
Yes, most of the time
Yes, some of the time
Not very often
No, never
�. � have been anxious or worried for no good reason:
No, not at all
Hardly ever
Yes, sometimesYes, very often
5. � have felt scared or panicky for no very
good reason:
Yes, quite a lot
Yes, sometimes
No, not much
No, not at all
6. things have been getting on top of me:
Yes, most of the time I haven’t been able to cope at all
Yes, sometimes I haven’t been coping as well as usual
No, most of the time I have coped quite well
No, I have been coping as well as ever
7. � have been so unhappy that � have had
difficulty sleeping:
Yes, most of the time
Yes, sometimes
Not very often
No, not at all
8. � have felt sad or miserable:
Yes, most of the time
Yes, quite often
Not very often
No, not at all
9. � have been so unhappy that � have
been crying:
Yes, most of the time
Yes, quite often
Only occasionally
No, never
�0. the thought of harming myself has
occurred to me:
Yes, quite often
Sometimes
Hardly ever
Never
PaGe �� NSW HealtH SaFe StaRt strategic policy
Edinburgh post natal depression scale (antenatal)
(Cox J, Holden J. 2003)
APPENDIx 1B
Date __________________________________________
Mother’s name_________________________________
Age ____________________Baby’s name ___________
Date of birth_____________Sex ___________________
as you have recently had a baby we would like to
know how you are feeling. Please UNDeRl�Ne the
answer which comes closest to how you have felt �N
tHe PaSt 7 DaYS, not just how you feel today. Here is
an example, already completed.
� have felt happy:
Yes, all the time
Yes, most of the time
No, not very often
No, not at all
this would mean: “� have felt happy most of the time”
during the past week. Complete the other questions
in the same way.
�. � have been able to laugh and see the funny side of things:
As much as I always could
Not quite so much now
Definitely not so much now
Not at all
2. � have looked forward with enjoyment to things:
As much as I ever did
Rather less than I used to
Definitely less than I used to
Hardly at all
3. � have blamed myself unnecessarily when things went wrong:
Yes, most of the time
Yes, some of the time
Not very often
No, never
�. � have been anxious or worried for no good reason:
No, not at all
Hardly ever
Yes, sometimes
Yes, very often
5. � have felt scared or panicky for no very good reason:
Yes, quite a lot
Yes, sometimes
No, not much
No, not at all
6. things have been getting on top of me:
Yes, most of the time I haven’t been able to cope at all
Yes, sometimes I haven’t been coping as well as usual
No, most of the time I have coped quite well
No, I have been coping as well as ever
7. � have been so unhappy that � have had difficulty sleeping:
Yes, most of the time
Yes, sometimes
Not very often
No, not at all
8. � have felt sad or miserable:
Yes, most of the time
Yes, quite often
Not very often
No, not at all
9. � have been so unhappy that � have been crying:
Yes, most of the time
Yes, quite often
Only occasionally
No, never
�0. the thought of harming myself has occurred to me:
Yes, quite often
Sometimes
Hardly ever
Never
NSW HealtH SaFe StaRt strategic policy PaGe �5
�. � have been able to laugh and see the funny side of things:
0 As much as I always could
1 Not quite so much now
2 Definitely not so much now
3 Not at all
2. � have looked forward with enjoyment to things:
0 As much as I ever did
1 Rather less than I used to
2 Definitely less than I used to
3 Hardly at all
3. � have blamed myself unnecessarily when things went wrong:
3 Yes, most of the time
2 Yes, some of the time
1 Not very often
0 No, never
�. � have been anxious or worried for no good reason:
0 No, not at all
1 Hardly ever
2 Yes, sometimes
3 Yes, very often
5. � have felt scared or panicky for no very good reason:
3 Yes, quite a lot
2 Yes, sometimes
1 No, not much
0 No, not at all
6. things have been getting on top of me:
3 Yes, most of the time I haven’t been
able to cope at all
2 Yes, sometimes I haven’t been coping as well as usual
1 No, most of the time I have coped quite well
0 No, I have been coping as well as ever
7. � have been so unhappy that � have had difficulty sleeping:
3 Yes, most of the time
2 Yes, sometimes
1 Not very often
0 No, not at all
8. � have felt sad or miserable:
3 Yes, most of the time
2 Yes, quite often
1 Not very often
0 No, not at all
9. � have been so unhappy that � have been crying:
3 Yes, most of the time
2 Yes, quite often
1 Only occasionally
0 No, never
�0. the thought of harming myself has occurred to me:
3 Yes, quite often
2 Sometimes
1 Hardly ever
0 Never
Edinburgh Postnatal Depression Scale scoring guide
Score for each question has been inserted on the left‑hand side of each possible response. add the scores for each question to calculate a total score out of a possible 30.
APPENDIx 1C
PaGe �6 NSW HealtH SaFe StaRt strategic policy
Psychosocial risk variables I–VII
APPENDIx 2
Variables (Risk Factors) Suggested format for psychosocial assessment questions
I. Lack of support 1. Will you be able to get practical support with your baby?
2. Do you have someone you are able to talk to about your feelings or worries?
II. Recent major stressors in the last
12 months.
3. Have you had any major stressors, changes or losses recently (ie in the last 12
months) such as, financial problems, someone close to you dying, or any other
serious worries?
III. Low self-esteem (including lack of
self-confidence, high anxiety and
perfectionistic traits)
4. Generally, do you consider yourself a confident person?
5. Does it worry you a lot if things get messy or out of place?
IV. History of anxiety, depression
or other mental health problems
6a. Have you ever felt anxious, miserable, worried or depressed
for more than a couple of weeks?
6b. If so, did it seriously interfere with your work and your relationships
with friends and family?
7. Are you currently receiving, or have you in the past received, treatment
for any emotional problems?
V. Couple’s relationship problems
or dysfunction (if applicable)
8. How would you describe your relationship with your partner?
9. a). antenatal: What do you think your relationship will be like after the birth OR
9. b). Postnatal (in Community Health Setting): Has your relationship changed since having the baby?
VI. Adverse childhood experiences 10. Now that you are having a child of your own, you may think more about
your own childhood and what it was like.
As a child were you hurt or abused in any way (physically, emotionally, sexually)?
VII. Domestic violence.
Questions must be asked only when
the woman can be interviewed away
from partner or family member
over the age of three years. Staff
must undergo training in screening
for domestic violence before
administering questions
11. Within the last year have you been hit, slapped, or hurt in other ways
by your partner or ex-partner?
12. Are you frightened of your partner or ex-partner?
(�f the response to questions �� & �2 is “No” then offer the
DV information card and omit questions �3‑�8)13. Are you safe here at home? /to go home when you leave here?
14. Has your child/children been hurt or witnessed violence?
15. Who is/are your children with now?
16. Are they safe?
17. Are you worried about your child/children’s safety?
18. Would you like assistance with this?
Opportunity to disclose further 19. Are there any other issues or worries you would like to mention?
NSW HealtH SaFe StaRt strategic policy PaGe �7
SAFE START models Strengths Potential issues
Specialist SaFe StaRt teamDedicated team.
Main role is to effect sustainable change in service in short period of time.
Useful when service providers
identify a need for urgent changes
in service delivery.
Identified resources and process for
education, service development,
evaluation and research activities.
■
■
SAFE START not perceived by mainstream
services as within their core practice.
Dialogue with SAFE START team rather
than between services.
Substantial ongoing funding required.
■
■
■
SaFe StaRt CoordinatorDedicated position
Main roles are to:put into effect sustainable changes in clinical practice
develop and monitor organisational change.
■
■
Promotes the identification of
pathways to care and recognition
of gaps in service delivery.
Conducive to clinical action research.
Favourable to the building of links
between services.
Most useful at AHS level as it promotes
sustainable change and standardisation of
practice.
■
■
■
■
Complexity of the role is highly
challenging and may be difficult
to sustain.
Recruitment of a multi-skilled mental
health specialist able to meet the
complexity of the role may be difficult.
Challenge of working across health
sectors especially when the service
configuration is varied and some
population groups have high needs.
■
■
■
Whole of aHS responsibilityDuties associated with SAFE
START are incorporated into
current roles.
Capacity building model.
Shared sector ownership.
Potential to improve motivation
of all staff, in regard to SAFE START
activity.
Enhance partnerships between services,
organisations, and relevant agencies.
SAFE START becomes core business.
Increased sustainability.
Involves limited expenses.
■
■
■
■
■
■
■
Potentially slower organisational change.
Dependent on leaders sustaining focus on
SAFE START.
Strong senior management support and
sponsorship required.
■
■
■
Strengths and issues - models of SAFE START implementation
APPENDIx 3
PaGe �8 NSW HealtH SaFe StaRt strategic policy
References
Alder, J., Fink, N., Bitzer, J., Hosli, R., Holzgreve, W. 2007,
Depression and anxiety during pregnancy: A risk factor for
obstetric, fetal and neonatal outcome? A critical review of
the literature. The Journal of Maternal‑Fetal and Neonatal
Medicine, March 20(3), pp. 189–209.
Barnett, B., Schaafsma, M.F., Guzman, A.M. & Parker,
G. 1991, Maternal anxiety: A 5-year review of an
intervention study. Journal of Child Psychology and
Psychiatry, Vol. 33, pp. 423-438.
Australian Health Ministers, 1992, National Mental
Health Policy. Canberra: Australian Government.
Australian Health Ministers, 1992, Mental Health
Statement of Rights and Responsibilities, Canberra:
Australian Government.
Australian Health Ministers, 2003, National Mental Health
Plan 2003–2008. Australian Government, Canberra.
Commonwealth Department of Health and Aged Care
2000, National Action Plan for Promotion, Prevention
and Early Intervention for Mental Health. Mental
Health and Special Programs Branch, Commonwealth
Department of Health and Aged Care, Canberra.
Council of Australian Governments (COAG), 2006,
National Action Plan on Mental Health 2006 – 2011.
Commonwealth Government, Canberra.
Cox, J., Holden, J., Sagovsky, R. 1987, Detection of
postnatal depression: development of the 10-item
Edinburgh postnatal depression scale. British Journal of
Psychiatry, Vol. 150, pp. 782–786.
Cox, J. and Holden, J., 2003, Perinatal Mental Health:
A Guide to the Edinburgh Postnatal Depression Scale
(EPDS). Gaskell, London.
Cox, J., Murray, D and Chapman, G., 1993, A controlled
study of the onset, duration and prevalence of postnatal
depression, The British Journal of Psychiatry, Vol. 163,
pp. 27 – 31.
Gotlib, L., Whiffen, V., Mount, K., Cordy, N. 1989,
Prevalence rates and demographic characteristics
associated with depression in pregnancy and the
postpartum. Journal of Consulting and Clinical
Psychology, Vol. 57(2), pp. 269–274.
Kendell, R., Chalmers, J., Platz, C. 1987, Epidemiology
of puerperal psychosis. British Journal of Psychiatry, 150,
pp. 662–673.
Llewellyn, A., Stowe, Z., Nemeroff, C.1997,
Depression during pregnancy and the puerperium.
Journal of Clinical Psychiatry, Vol. 58, pp. 26–32
Mrazek, P.J. and Haggerty, R.J. (eds) 1994, Reducing
risks for mental disorders: Frontiers for preventive
intervention research. Institute of Medicine, National
Academy Press, Washington DC.
Murray, L. 1992, The impact of postpartum depression
on infant development. Journal of Child Psychiatry,
Vol. 33, pp. 543–561.
National Collaborating Centre for Mental Health, 2007,
Antenatal and Postnatal Mental Health: The NICE
Guideline on clinical management and service guidance.
National Clinical Practice Guideline Number 45, The
British Psychological Society and Gaskell.
O’Hara, M. Swain, A. 1996, Rates or risks of postpartum
depression – a meta-analysis. International Journal of
Psychiatry, Vol. 8, pp. 37–54.
Puckering, C., 2004, Parenting in social and economic
adversity, In: Hoghugh M., Long, N., (Eds) Handbook
of parenting: theory and research for practice, Sage
Publications, London, pp. 38–54.
Seeman, M. 2000, Women and schizophrenia.
Medscape Women’s Health, Vol. 5, No 2.
Smatmari, P., Nagy, J. 1990, Children of schizophrenic
parents; a critical review of issues in prevention. Journal
of Preventive Psychiatry and Allied Disciplines, Vol. 4, pp.
311–327.
Swain, J.E., Lorberbaum, J.P., Kose, S., Strathearn, L.,
2007, Brain basis of early parent-infant interactions:
psychology, physiology, and in vivo functional
neuroimaging studies. Journal of Child Psychology
and Psychiatry, 48:3/4, pp. 262–287.
Viguera, A., Nonacs, R., Cohen, L. et al., 2000, Risk of
recurrence of bipolar disorder in pregnant and non-
pregnant women after discontinuing lithium maintenance.
The American Journal of Psychiatry, Vol. 157, pp. 179-184.
SHPN ( PHCP) 080164 Photography www.shutterstock.com